Microsoft Word Acute Onset of Scrotal Pain Without Trauma, Without Antecedent Mass

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1 Revised 2018 American College of Radiology ® ACR Appropriateness Criteria Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, wi thout antecedent mass. Initial imaging. Relative Radiation Level Appropriateness Category Procedure US duplex Doppler scrotum Usually Appropriate O MRI pelvis (scrotum) without and with IV May Be Appropriate O contrast Usually Not Appropriate Tc-99m scrotal scintigraphy ☢☢☢ Usually Not Appropriate MRI pelvis (scrotum) without IV contrast O ® Acute Onset of Scrotal Pain 1 ACR Appropriateness Criteria

2 ACUTE ONSET OF SCROTAL PAIN-WITHOUT TRAUMA, WITHOUT ANTECEDENT MASS a b c Expert Panel on Urological Imaging: Carolyn L. Wang, MD ; Aytekin Oto, MD ; Barun Aryal, MD ; f g d e Brian C. Allen, MD ; Oguz Akin, MD ; Lauren F. Alexander, MD ; Dianna M. E. Bardo, MD ; k i j h Jaron Chong, MD ; Pat F. Fulgham, MD ; ; Matthew T. Heller, MD ; Adam T. Froemming, MD m l n o Jodi K. Maranchie, MD ; Rekha N. Mody, MD ; Nicola Schieda, MD ; ; Bhavik N. Patel, MD, MBA p s q r Ismail B. Turkbey, MD ; Don C. Yoo, MD ; Aradhana M. Venkatesan, MD ; Mark E. Lockhart, MD, MPH. Summary of Literature Review Introduction/Background An acute scrotum is defined as testicular swelling with acute pain and can reflect multiple etiologies, including epididymitis or epididymo-orchitis, torsion of the spermati c cord, or torsion of the testicular appendages. Quick and accurate diagnosis of acute scrotum and its etiology is necessary because a delayed diagnosis of torsion for as little as 6 hours can cause irreparable testicular damage [1,2]. The single most common cause for acute scrotal pain is epididymitis. There are approximately 600,000 cases of epididymitis diagnosed every year in the United States [3]. Infection is commonly seen in patients 19 to 25 years of age, and overwhelmingly is the etiology for acute scrotum in patients >25 years of age [3]. Torsion is rare in patients >35 years of age [4]. from torsion of the testicular appendages, a process Acute scrotum in prepubertal boys occurs most commonly [2,4]. The pathognomonic physical examination finding of that can mimic testicular torsion or epididymo-orchitis rinatal testicular torsion is not uncommon, accounting for the “blue dot sign” is infrequently encountered [1]. Pe 10% of cases in children [5]. Testicular torsion typically presents as abrupt scrotal pain, whereas epididymitis has a more gradual pain onset. ; however, this does not exclude epididymitis [6]. There is overlap Patients with torsion can have normal urinalysis in the clinical presentation of different causes of acute scrotal pain. For the pediatric patient (3 months–18 years of age), a clinically validated scoring system—Tes ticular Workup for Ischemia and Suspected Torsion (TWIST)—has been shown to have high positive predic tive values. Patients with high TWIST scores should go on to urological evaluation rather than imaging; although , studies suggest that low and intermediate risk groups will benefit from Doppler ultrasound (US) [7,8]. In equivocal cases, imaging can augment the clinical examination findings and either diagno se testicular torsion early enough to sal vage the testicle or identify other etiologies to prevent unnecessary operations [9,10]. A study comparing primary scrotal exploration (294 patie nts) and initial US examination (332 patients) with exploration for positive US results or a high clinical suspic ion of torsion [11] showed that US obviated the need for exploration in many patients and thus shortened hospital stays. A more recent study in 258 young men who were between 3 months and 18 years in age compared the TWIST scores and initial US demonstrated receiver operator characteristics curves for TWIST with an area under the curve of 0.82 versus 0.89 for US, and the results low-risk patients to avoid missing intermittent torsion suggested a Doppler US should still be performed even in or torsion that has atypical findings [8]. c b a Research Author, University of cer Care Alliance, Seattle, Washington. University of Washington, Seattle Can Panel Washington, Seattle, Washington. e d Memorial Sloan Kettering Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina. Chair, University of Chi cago, Chicago, Illinois. g h f Mayo Clinic, Jacksonville, Florida. Phoenix Children’s Hospital, Phoenix, Arizona. McGill University, Montreal, Cancer Center, New York, New York. k i j Mayo Clinic, Rochester, Minnesota. Urology Clinics of North Texas, Dallas, Texas; American Urological Association. University of Quebec, Canada. m n l Stanford UPMC, Pittsburgh, Pennsylvania; Am erican Urological Association. Cleveland Clinic, Cleveland, Ohio. Pittsburgh, Pittsburgh, Pennsylvania. o Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, University Medical Center , Stanford, California. r p q lth, Bethesda, Maryland. The University of Texas MD Anderson Cancer Center, Houston, Texas. Rhode Island National Institutes of Hea Ontario, Canada. s Specialty Chair, University of Alabama at Birmingham, Hospital/The Warren Alpert Medical School of Brown University, Providence, Rhode Island. Birmingham, Alabama. The American College of Radiology seeks and encourages collabor ation with other organizations on the development of the ACR Ap propriateness Criteria through society representation on expert panels. Particip ation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endor sement of the final document. [email protected] Reprint requests to: ® Acute Onset of Scrotal Pain 2 ACR Appropriateness Criteria

3 Discussion of Procedures by Variant Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging. s with acute pain, without history of trauma, and no history of antecedent This criterion will be limited to patient scrotal or testicular mass since these scenarios may affect management plans. US Duplex Doppler Scrotum oppler examination of the bilateral scrotal and inguinal Standard US of the scrotum includes both grayscale and D areas. Although grayscale is less sensitive for torsion, it can help identify other diagnoses, such as inflammation sses. Additionally, a normal homogenous echo pattern is less that is due to epididymitis or solid/cystic scrotal ma likely to represent a nonviable testis than an inhomogenous testis on grayscale imaging [12]. Real-time grayscale imaging is most helpful to identify a spermatic cord “twist” as seen in 199 of 208 patients (sensitivity 96%), whereas a normal linear cord was found in patients without torsion (705 of 711 patients, 99% specificity) [13,14]. This twisted cord finding is known as the “whirlpool sign” and can be seen above the testis, external to the inguinal ring [14,15]. A cine clip in transverse plane moving along the course of the spermatic cord can help identify the finding. Testicular perfusion is best assessed by color Doppler US [12,16]. Duplex Doppler is another often employed tool that involves acquisition and display of color Doppler and spectral Doppler waveforms in conjunction with grayscale sonographic imaging. Power Doppler US can be u sed in place of, or as an adjunct to, color Doppler US. Power Doppler has been shown to be more sensitive than color Doppler, especi ally when evaluating areas of slow flow [12]. Power Doppler is especially useful to dem onstrate intratesticular flow in prepubertal testes [17]. Reported sensitivity of color Doppler US in detecting tors ion ranges from 96% to 100%, with a specificity of 84% to 95% [18]. In a series of 132 cases of acute scrotum, color Doppler US showed sensitivity of 91.7% and a specificity of 99.2% [19]. A negative US examination is highly predictive of the absence of torsion at the time of presenting with acute scrotum, duplex Doppler US had imaging [20]. In a prospective study of 104 boys sensitivity of 91% (95% confidence city of 87% (95% CI: 81.3%–89.0%), fi interval [CI]: 61.2%–99.5%), speci and accuracy of 90% (95% CI: 79.9%–92.4%) for diagnosis of testicular torsion [7]. In a retrospective analysis of Doppler US evaluation of 498 patients with acute scrot um, sensitivity of 75.8%, specificity of 98.9%, and diagnostic accuracy of 97.6% was determined for the evalua tion of testicular torsion, and the authors found that Doppler US significantly increased the predictivity of the diagnostic process for acute scrotum [9]. Blood flow can be preserved in patients despite torsion, wh ich is a potential pitfall of color Doppler [14,21,22]. Spectral Doppler waveform patterns (high-resistance arteri al and monophasic waveforms) [22] and spermatic cord morphology (twisted or thickened spermatic cord ) can help diminish false-negative results. In adults and adolescent boys, epididymo-orchitis is th e most common cause of acute scrotal pain. On US, the epididymis is enlarged, has increased flow on color Doppl er, and can be increased or decreased in echogenicity. es in patients with epididymitis report up to a 20% Scrotal wall thickening and hydrocele are common. Studi concomitant rate for orchitis [23]. Rarely, acute epid idymo-orchitis can be complicated by global testicular infarction, which has been associated with a juxtaepididymal color Doppler signal with a “string-of-beads” appearance [24]. The most common cause of scrotal pain in children is torsion of the appendix testis [25]. Reactive changes (hydrocele, epididymal head enlargem ent, increased color Doppler flow) from torsion of a testicular appendage may mimic epididymitis [4]. A torsed testicular appendage can be difficult to see by US. A size criterion of >5.6 mm may discriminate a torsed testicular appendage but has low sensitivity (57%) and high specificity (100%), which sometimes obviates the need for surgery [26]. Scrotal fat necrosis is an uncommon but comparatively beni gn etiology of scrotal pain. Typically, the patient is a prepubescent boy with recent cold exposure, often from swimming. Bilateral intrascrotal masses caudal to the testes are palpated, and the testes appear normal on US, while the caudal scrotal fat is characteristically rior shadowing [27]. hyperechoic with poste n age 37–38 years) is segmental testicular infarction An uncommon cause of scrotal pain in adult men (media [28,29]. Classic imaging appearance is a wedge-shaped avascular focal area on US; however, other studies have ow in one series [28]. If US is equivocal, MRI can be helpful to identify shown round lesions and color Doppler fl ® Acute Onset of Scrotal Pain 3 ACR Appropriateness Criteria

4 segmental testicular infarction [29]. Contrast-enhanced US is a technique that may be used to evaluate for infarction; although, as of 2018, US contrast is not yet FDA approved for scrotal imaging [30,31]. Acute idiopathic scrotal edema is rare and self-limiting, commonly observed in children, and is a diagnosis of exclusion. Acute idiopathic scrotal edema is usually painless and classically has marked thickening of the scrotal wall with heterogeneous striated and edematous appear ance with increased vascularity on US [32,33]. Other reactive hydrocele and enlargement, and increased findings include increased peritesticular blood flow, and epididymis are normal and do not show increased vascularity of the inguinal lymph nodes [33]. The testes vascularity. MRI Pelvis (Scrotum) MRI techniques are not typically used for the evaluation of acute scrotum. However, there has been increased use of MRI in assessing scrotal disease [1,34,35]. A retrospectiv e study of 39 patients with acute scrotum reports that MRI has a 93% sensitivity and 100% specificity for diagnosing testicular torsion [35]. The most sensitive finding in torsion is decreased or lack of perfusion on dynamic contrast-enhanced MRI [36]. Other characteristics include low or very low signal inte nsities with spotty or streaky patterns on fat-suppressed T2-weighted, heavily T2-weighted, or T2*-weighted images [36]. The use of a combination of dynamic contrast- enhanced T1-weighted MRI with T2-weighted and T2*-we ighted sequences may help distinguish patients with torsion alone from those with torsion and hemorrhagic n ecrosis [36]. To aid diagnosis, diffusion restriction and apparent diffusion coefficient (ADC) may be useful to di fferentiate testicular torsion from other scrotal disorders with the twisted testes having statistically lower mean ADC values than nonaffected testes, and the affected to termittent torsion nonaffected ratio ADC value was also si gnificantly lower [37]. However, MRI cannot rule out in [36]. be seen on MRI-unenhanced T1-weighted images as Although uncommon, segmental testicular infarction can subtle central high-signal intensity from a focal hemorrh age. On T2-weighted images, it is well marginated but has variable signal intensity. With gadolinium chelate contrast, the lesion is avascular but circumscribed by an enhancing rim [29]. However, use of noncyclic gadoliniu m chelate agents in patients with end-stage chronic kidney disease or acute kidney injury risks developing nephrogenic systemic fibrosis [37]. Tc-99m Scrotal Scintigraphy Radionuclide scrotal imaging (RNSI) is uncommonly used and has been essentially replaced by Doppler US as the primary imaging modality for evaluation of the acute scrotum. RSNI may be used for further characterization and has reported sensitivity and specificity ranges for differentiation between testicul ar torsion and epididymo- orchitis from 89% to 98% and 90% to 100%, respectively [17,38,39]. One series, published in 1998, reported RSNI as a useful problem-solving tool in cases where US is equivocal [40]. However, RSNI is limited by technical challenges in children who have small genitalia , which are difficult to image with radiotracers. RNSI also can have photon-deficient areas secondary to hydrocele and spermatocele, and rarely inguinal hernias, which can be erroneously diagnosed as avascular testis [41]. Summary of Recommendations  Variant 1: US duplex Doppler of the scrotum is usually a ppropriate as the initial imaging for the acute onset of scrotal pain without trauma or antecedent mass in an adult or ch ild. Supporting Documents pendix for this topic are available at https://acsearch.acr.org/list. The The evidence table, literature search, and ap und tabulations for each appendix includes th e strength of evidence assessment and the final rating ro recommendation. For additional information on the Appropriateness Crite ria methodology and other supporting documents go to www.acr.org/ac. ® Acute Onset of Scrotal Pain 4 ACR Appropriateness Criteria

5 Appropriateness Category Names and Definitions Appropriateness Appropriateness Category Definition Appropriateness Category Name Rating The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk- Usually Appropriate 7, 8, or 9 benefit ratio for patients. The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with 4, 5, or 6 May Be Appropriate a more favorable risk-benef it ratio, or the risk-benefit ratio for patients is equivocal. The individual ratings are too dispersed from the panel median. The different label provides May Be Appropriate transparency regarding the panel’s recommendation. 5 (Disagreement) “May be appropriate” is the rating category and a rating of 5 is assigned. The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the Usually Not Appropriate 1, 2, or 3 risk-benefit ratio for patients is likely to be unfavorable. Relative Radiation Level Information Potential adverse health eff ects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with vel (RRL) indication has been included for each imaging different diagnostic procedures, a relative radiation le examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imagi ng procedure. Patients in the pediatric age group are at n sensitivity and longer life expectancy (relevant to the inherently higher risk from exposure, because of both orga long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with t hose specified for adults (see Table below). Additional information regarding radiation dose assessment fo r imaging examinations can be found in the ACR ® Appropriateness Criteria Radiation Dose Assessment Introduction document [42]. Relative Radiation Level Designations Adult Effective Dose Estimate Pediatric Effective Dose Estimate Relative Radiation Level* Range Range 0 mSv 0 mSv O <0.03 mSv <0.1 mSv ☢ 0.1-1 mSv 0.03-0.3 mSv ☢☢ 1-10 mSv 0.3-3 mSv ☢☢☢ 10-30 mSv 3-10 mSv ☢☢☢☢ 30-100 mSv 10-30 mSv ☢☢☢☢☢ patient doses in these procedures vary *RRL assignments for some of the examin ations cannot be made, because the actual as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” References 2008;62:821-7. 1. Kapoor S. Testicular torsion: a race against time. Int J Clin Pract ® Acute Onset of Scrotal Pain 5 ACR Appropriateness Criteria

6 2. Pogorelic Z, Mustapic K, Jukic M, et al. Manageme nt of acute scrotum in children: a 25-year single center 2016;23:8594-601. experience on 558 pediatric patients. Can J Urol 3. Lorenzo L, Rogel R, Sanchez-Gonzalez JV, et al. Evaluation of Adult Acute Scrotum in the Emergency Room: Clinical Characteristics, Diagnos 2016;94:36-41. is, Management, and Costs. Urology 4. Karmazyn B, Steinberg R, Livne P, et al. Duplex sonographic findings in children with torsion of the 2006;41:500-4. idymitis and epididymoorchitis. J Pediatr Surg testicular appendages: overlap with epid 5. Sanguesa Nebot C, Llorens Salvador R, Pico Aliaga S, Garces Inigo E. Perinatal testicular torsion: ultrasound assessment and differential diagnosis. Radiologia 2017;59:391-400. in children with epididymitis. Eur J Pediatr Surg 2010;20:247- 6. Graumann LA, Dietz HG, Stehr M. Urinalysis 9. 7. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int 2013;112:1201-6. 8. Frohlich LC, Paydar-Darian N, Cilento BG, Jr., Lee LK . Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum. Acad Emerg Med 2017;24:1474-82. G, Schleef J. Predictivity of Clinical Findings and 9. Lemini R, Guana R, Tommasoni N, Mussa A, Di Rosa 2016;13:2779-83. Doppler Ultrasound in Pediatric Acute Scrotum. Urol J oradiology Taskforce--imaging recommendations in 10. Riccabona M, Darge K, Lobo ML, et al. ESPR Ur ography, imaging disorder of sexual development and paediatric uroradiology, part VIII: retrograde urethr imaging childhood testicular torsion. Pediatr Radiol 2015;45:2023-8. 11. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppl er ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Pediatr Radiol 2005;35:597-600. 12. Sparano A, Acampora C, Scaglione M, Romano L. Using color power Doppler ultrasound imaging to diagnose the acute scrotum. A pictorial essay. Emerg Radiol 2008;15:289-94. 13. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assess ment of ultrasound of the spermatic cord in children with acute scrotum. J Urol 2007;177:297-301; discussion 01. , Cisek LJ. Intermittent testicular torsion in the 14. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF pediatric patient: sonographic indicators of a difficult diagnosis. AJR Am J Roentgenol 2013;201:912-8. 15. Vijayaraghavan SB. Sonographic differe ntial diagnosis of acute scrotum: real-time whirlpool sign, a key sign 2006;25:563-74. of torsion. J Ultrasound Med 16. Yagil Y, Naroditsky I, Milhem J, et al. Role of D oppler ultrasonography in the triage of acute scrotum in the 2010;29:11-21. emergency department. J Ultrasound Med 17. Yu KJ, Wang TM, Chen HW, Wang HH. The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsio n and epididymo-orchitis. Chang Gung Med J 2012;35:38-45. 18. Altinkilic B, Pilatz A, Weidner ar perfusion using color coded duplex W. Detection of normal intratesticul sonography obviates need for scrotal exploration in pa tients with suspected testicular torsion. J Urol 2013;189:1853-8. 19. Stehr M, Boehm R. Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children. Eur J Pediatr Surg 2003;13:386-92. 20. Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. AJR Am J Roentgenol 2013;200:W444-9. 21. Bentley DF, Ricchiuti DJ, Nasrallah PF, McMahon DR . Spermatic cord torsion with preserved testis 2004;172:2373-6. perfusion: initial anatomical observations. J Urol 22. Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum. J Ultrasound Med 2004;23:1077-85. 23. Pilatz A, Wagenlehner F, Bschleipfer T, et al. Acut e epididymitis in ultrasound: results of a prospective study with baseline and follow-up investiga tions in 134 patients. Eur J Radiol 2013;82:e762-8. 24. Chang CD, Lin JW, Lee CC, et al. Acute Epididymo-or chitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the J uxta-epididymal String-of-Bead Sign. Ultrasound Q 2016;32:283-9. 25. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005;35:302-10. 26. Baldisserotto M, de Souza JC, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed 2005;184:1287-92. testicular appendages in children. AJR Am J Roentgenol appearance of scrotal fat necrosis in prepubertal boys. 27. Harkness G, Meikle G, Craw S, Samalia K. Ultrasound 2007;37:370-3. Pediatr Radiol ® Acute Onset of Scrotal Pain 6 ACR Appropriateness Criteria

7 28. Bilagi P, Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Clinical and ultrasound features of 2007;17:2810-8. segmental testicular infarction: six-year experience from a single centre. Eur Radiol 29. Fernandez-Perez GC, Tardaguila FM, Velasco M, et al al testicular infarction. . Radiologic findings of segment AJR Am J Roentgenol 2005;184:1587-93. 30. Bertolotto M, Derchi LE, Sidhu PS, et al. Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up. AJR Am J Roentgenol 2011;196:834-41. 31. Valentino M, Bertolotto M, Derchi L, et al. Role of contrast enhanced ultrasound in acute scrotal diseases. Eur Radiol 2011;21:1831-40. 32. Geiger J, Epelman M, Darge K. The fountain sign: a novel color Doppler sonographic finding for the scrotal edema. J Ultrasound Med diagnosis of acute idiopathic 2010;29:1233-7. 33. Lee A, Park SJ, Lee HK, Hong HS, Lee BH, Kim DH. Acute idiopathic scrotal edema: ultrasonographic 2009;19:2075-80. findings at an emergency unit. Eur Radiol 34. Makela E, Lahdes-Vasama T, Ryymin P, et al. Ma gnetic resonance imaging of acute scrotum. Scand J Surg 2011;100:196-201. 35. Terai A, Yoshimura K, Ichioka K, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology 2006;67:1278-82. 36. Watanabe Y, Nagayama M, Okumur a A, et al. MR imaging of testicular torsion: features of testicular hemorrhagic necrosis and clinical outcomes. J Magn Reson Imaging 2007;26:100-8. 37. Maki D, Watanabe Y, Nagayama M, et al. Diffusion- weighted magnetic resonance imaging in the detection of testicular torsion: feasibility study. J Magn Reson Imaging 2011;34:1137-42. agnostic nuclear medicine in the ED. Am J Emerg Med 38. Amini B, Patel CB, Lewin MR, Kim T, Fisher RE. Di 2011;29:91-101. 39. Melloul M, Paz A, Lask D, Manes A, Mukamel E. Th e value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion. Br J Urol 1995;76:628-31. ski D, Treves ST. Acute scrotal symptoms in boys 40. Paltiel HJ, Connolly LP, Atala A, Paltiel AD, Zurakow ison of color Doppler sonography and scintigraphy. with an indeterminate clinical presentation: compar 1998;207:223-31. Radiology 41. Hod N, Maizlin Z, Strauss S, Horne T. The relative me rits of Doppler sonography in the evaluation of patients 2004;6:13-5. ed testicular torsion. Isr Med Assoc J with clinically and scintigraphically suspect ® 42. American College of Radiol ogy. ACR Appropriateness Criteria Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness- Criteria/RadiationDoseAssessmentIntro.pdf. Accessed November 30, 2018. The ACR Committee on Appropriateness Criteria developed criteria for dete rmining appropriate imaging examinations for and its expert panels have diagnosis and treatment of specified medi cal condition(s). These criteria are intende d to guide radiologist s, radiation oncolog ists and referring physicians in making decisions regarding radiologic imag ing and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally us ed for evaluation of the patient ’s condition are ranked. considered in this Other imaging studies necessary to evaluate other co-existent di seases or other medical consequences of this condition are not s. Imaging techniques ppropriate imaging procedures or treatment document. The availability of equipment or personnel may influence the selection of a and applications should classified as investigational by the FDA have not been consider ed in developing these criteria; however, study of new equipment of any specific radiologic examination or treatment must be be encouraged. The ultimate decision regarding the appropriateness made by the referring physician and radiologist in light of all the circum stances presented in an individual examination. ® Acute Onset of Scrotal Pain 7 ACR Appropriateness Criteria

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Chapter 3 - More About Alcoholism - (pp. 30-43)

Chapter 3 - More About Alcoholism - (pp. 30-43)

Chapter 3 MORE ABOUT ALCOHOLISM have been unwilling to admit we ost of us M were real alcoholics. No person likes to think he is bodily and mentally different from his fellows. Ther efore, it is not s...

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